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  • Hospital patient died after choking incident

    Despite being regarded as at risk of aspiration, a frail and elderly main died after a choking incident. HM Assistant Coroner Graeme Irvine heard at the inquest into the death

    Mr Boardman was an elderly and frail man who experienced a decline in his health in late 2019. After being mistakenly sent home by the Royal London Hospital the patient was readmitted shortly before Christmas.

    Following a period of inpatient care at the Royal London Hospital Mr Boardman was assessed by his local borough. He was deemed to require a placement in sheltered accommodation with four daily domiciliary care visits.

    On the 17th December 2019 Mr Boardman was mistakenly discharged to his home address by the hospital, an error discovered by the London Borough of Tower Hamlets on 18th December 2019 when he did not arrive at his sheltered accommodation.

    They immediately contacted the hospital who could not assist with Mr
    Boardman’s whereabouts as no note had been made by the discharge
    note regarding where he had been taken.

    Mr Boardman was locatd at his home address – which had no heating, light or food – and taken to his sheltered accommodation where he was assessed to have deteriorated and was was readmitted to hospital.

    Whilst there Mr Boardman was assessed and determined to be at risk of aspiration was required to be give soft food, in small pieces, whilst supervised.

    On the evening of 26th December 2019 he was found in his room eating a whole fruit whilst unsupervised. The fruit had not been provided to him by the hospital, a quantity of fruit on his bed table was removed from his
    bedside.

    In the early hours of 27th December 2019 Mr Boardman was found to have experienced a choking incident, suction was utilised to remove aspirate.

    A witness indicated that a piece of fruit was found in the aspirate, other witnesses indicated this was not the case.

    As a DNACPR order was in place no attempt to commerce CPR was made by staff.